Gero: Cardiovascular, hematologic, and lymphatic systems
When a client suddenly develops second-degree heart block, type I, with a rate of 48 beats/minute, which action would the nurse take first? 1 Obtain a temporary pacemaker. 2 Give the prescribed PRN atropine. 3 Notify the health care provider. 4 Take the client's blood pressure
4 Take the client's blood pressure Because second-degree heart block, type I is usually transient and well tolerated, the nurse's first action would be to assess the client for adequate perfusion by checking parameters such as blood pressure, skin temperature, and alertness. A temporary pacemaker may be needed, but only if the assessment indicates a need to increase heart rate to adequately perfuse the client. Atropine is appropriate if the bradycardia has caused hypotension or decreased alertness, but may not be needed. Notification of the health care provider is appropriate, but the nurse should be able to provide information about blood pressure and other indicators of perfusion to the health care provider.
Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? 1 Obstructive 2 Neurogenic 3 Cardiogenic 4 Hypovolemic
4 Hypovolemic Hypovolemic shock occurs because of blood loss from the circulation when an abdominal aneurysm ruptures. Obstructive shock occurs from physical obstruction impeding the filling or outflow of blood, such as cardiac tamponade or pulmonary embolism. Neurogenic shock results from spinal cord or head injury, which cause vasodilation due to loss of sympathetic nervous system vasoconstrictor tone. Cardiogenic shock results from a decrease in cardiac output.
Which action would the nurse take first when caring for a client who has just returned to the intensive care unit after open-heart surgery? 1 Elevate the head of the bed to 30 degrees. 2 Suction the client through the endotracheal tube. 3 Check the pulse oximeter for oxygen saturation. 4 Auscultate the client's heart and lung sounds.
3 Check the pulse oximeter for oxygen saturation. Assessing oxygen saturation is a priority because hypoxemia may indicate post-operative complications such as bleeding or a displaced endotracheal tube. In addition, inadequate oxygenation can cause complications such as dysrhythmias. The head of the bed is usually elevated, but this would be done after ensuring that blood pressure is adequate to perfuse the brain with the head elevated. The client may need suctioning, but breath sounds would be assessed first, because unnecessary suctioning should be avoided. The heart and lung sounds will be assessed, but ensuring adequate oxygen saturation is the priority.
Which clinical manifestations are more likely to occur in women with coronary artery disease compared with men? Select all that apply. One, some, or all responses may be correct. 1 Severe fatigue 2 Sense of unease 3 Substernal chest pain 4 Shortness of breath 5 Pain radiating down the left arm
1 Severe fatigue 2 Sense of unease 4 Shortness of breath Women with coronary artery disease are more likely than men to describe initial clinical manifestations of severe fatigue unrelieved with adequate rest, a sense of unease with no identified cause, and feeling "unable to catch my breath". Men are more likely to present with "classic" symptoms such as substernal chest pain and pain radiating down the left arm. However, it is important to remember that any individual client may present any of the symptoms listed above, and the nurse would assess all clients for all potential clinical manifestations of coronary artery disease.
A client receiving intravenous fluids complains of pain at the insertion site, and the nurse notes erythema and edema. Based on the phlebitis scale, how would the nurse document the phlebitis? 1 Grade 1 2 Grade 2 3 Grade 3 4 Grade 4
2 Grade 2 According to the phlebitis scale, grade 2 presents as pain at the access site with erythema or edema. Grade 1 presents as erythema with or without pain. Grade 3 presents as pain at the access site with erythema or edema, streak formation, and palpable cord. Grade 4 presents as pain at the access site with erythema or edema, streak formation, palpable cord more than 1 inch long, and purulent drainage.
Which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
1 Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. As shock progresses, eventually respiratory acidosis can result from decreased respiratory function in late shock. Respiratory alkalosis may occur as a result of hyperventilation during early shock.
After a cardiac catheterization, a client's urinary output is 3 times the client's fluid intake. What is the likely cause of the high urinary output? 1. An expected effect of the dye used with the procedure 2. Increased cardiac output as a result of the procedure 3. Improvement of urinary functioning after the catheterization 4. A result of the prescribed intravenous (IV) rate of 50 mL/h
1. An expected effect of the dye used with the procedure The dye used is hypertonic and has a diuretic effect. A cardiac catheterization is a diagnostic procedure, not a therapeutic one; cardiac output will not improve after the procedure. Urinary function does not improve after cardiac catheterization. An IV rate of 50 mL/h will not cause a urinary output three times the amount of intake.
Which information would the nurse include when teaching a client with varicose veins about ligation and stripping surgery? 1 Plaque from within the veins is scraped. 2 The dilated saphenous veins are removed. 3 Superficial veins are sown together into deep veins. 4 An umbrella filter is placed in the large affected veins.
2 The dilated saphenous veins are removed. During ligation and stripping surgery, the saphenous vein is removed. Plaque occurs in arteries, not in the venous system. Anastomosing (sewing together) superficial veins to deep veins is not done during this surgery; superficial and deep veins usually are attached by communicating veins. An umbrella filter placed in the large affected veins prevents emboli from traveling to the lung in clients with chronic venous thrombosis; it is not a treatment for varicose veins.
When a client who has had abdominal surgery reports pain and swelling in the right leg, the nurse would anticipate teaching the client about which diagnostic test? 1 Right leg x-ray 2 Electrolyte levels 3 Venous ultrasound of pelvis and legs 4 Computerized tomography of abdomen
3 Venous ultrasound of pelvis and legs The client's history of abdominal surgery and report of right leg pain and swelling are consistent with possible right leg venous thrombosis, and the nurse would anticipate that the client will need a venous ultrasound of the pelvis and legs to detect possible venous thrombosis. There is no indication of a bony injury that would be diagnosed with an x-ray. Electrolyte levels would not be helpful in diagnosing venous thrombosis and are not needed before starting anticoagulant therapy. Computerized tomography of the abdomen might be used if abdominal complications were suspected, but this client has right leg symptoms.
Which action would the nurse take after noting that a client who has been on anticoagulant therapy after hip surgery is being discharged with no anticoagulant prescription? 1. Explain to the client that anticoagulant therapy will no longer be needed. 2. Suggest that the client take aspirin daily to prevent venous thrombosis. 3. Contact the health care provider to clarify whether anticoagulant therapy is needed. 4. Instruct the client to call the health care provider to ask about anticoagulant medications
3. Contact the health care provider to clarify whether anticoagulant therapy is needed. Because it is unclear what the anticoagulant needs are for this client, the nurse would contact the health care provider for clarification. The nurse would not tell the client that no anticoagulant was needed without further clarification. Daily aspirin use is not adequate to prevent venous thrombosis in clients at high risk, such as those who have had orthopedic surgery. The nurse would not place the responsibility for clarification about anticoagulant use on the client, because it is a nursing responsibility to clarify discharge medications and instructions.
When caring for a client who has hypokalemia, which electrocardiogram change will the nurse expect to observe? 1. Inverted P waves 2. Flattened T waves 3. Absence of U waves 4. Elevated ST segment
2. Flattened T waves A flattened T wave is associated with hypokalemia. A depressed T wave indicates a problem with ventricular repolarization, a process involved in muscle contraction. Adequate potassium levels are needed for efficient muscle contraction. P waves may peak in hypokalemia. In hypokalemia, U waves appear. ST segment is depressed in hypokalemia.
Where would the nurse place the stethoscope to listen for mitral valve insufficiency (regurgitation)? 1. a: second intercostal space, left sternal border 2. b: third intercostal space, left sternal border 3. c: second intercostal space, right sternal border 4. d: fifth intercostal space, midclavicular line
4. d: fifth intercostal space, midclavicular line (apex) Mitral valve heard during S1 Aortic valve > a: second intercostal space, left sternal border Heard during S2 Pumonary Valve > c: second intercostal space, right sternal border Heard during S2 Tricuspid valve > fifth intercostal space, left sternal border Heard during S1 Point c is not part of the assessment of the heart; this is the area over the right main bronchus, which is used to assess bronchovesicular breath sounds.
When caring for a client with peripheral arterial disease, which assessment findings will the nurse expect? Select all that apply. One, some, or all responses may be correct. 1 Absence of hair on the toes 2 Pink and moist ankle ulcers 3 Pitting edema of the lower legs 4 Reports of pain associated with exercising 5 Increased pigmentation of the medial malleolus area
1 Absence of hair on the toes 4 Reports of pain associated with exercising The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when arterial flow is impaired. Pink and moist ulcers are associated with venous insufficiency; arterial ulcers are pale and dry because of decreased blood flow. Pitting edema of the lower extremities is associated with venous insufficiency. Increased pigmentation of the medial and lateral malleolus areas is associated with venous insufficiency.
Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the health care provider? 1 Apical heart rate 55 beats per minute 2 Premature ventricular contractions 3 Serum potassium level 5 mEq/L (5 mmol/L) 4 Bilateral swelling of the lower extremities
1 Apical heart rate 55 beats per minute Digoxin toxicity can manifest with premature ventricular contractions (PVCs) or other ventricular dysrhythmias such as ventricular tachycardia or fibrillation. The nurse would communicate the presence of PVCs to the provider and anticipate collaborative actions such as checking digoxin level and potassium level. An apical heart rate of 55 would be reported, but some providers prefer a heart rate of 50 to 60 beats per minute, and no immediate change in treatment would be needed. Hypokalemia can lead to digoxin toxicity, but a serum potassium level of 5 mEq/L (5 mmol/L) would not increase risk for digoxin toxicity. Bilateral swelling of the lower extremities in a client with heart failure indicates a possible need for a change in treatment but is not life threatening.
Which findings in a client who has had major abdominal surgery indicate a possible venous thrombosis of the leg? Select all that apply. One, some, or all responses may be correct. 1 Edema of the ankle 2 Skin breakdown over the shin 3 Pruritus on the side of the calf 4 Tender area in the posterior lower leg 5 Warmth along the course of the involved vessel
1 Edema of the ankle 4 Tender area in the posterior lower leg 5 Warmth along the course of the involved vessel Venous thrombosis is a possible complication after surgery because of venous stasis during the procedure and decreased activity after surgery. Symptoms include swelling distal to the thrombosis, and pain and warmth over the area of the thrombosis. Skin breakdown may occur with chronic venous insufficiency, but not with acute venous thrombosis. Pruritus may also occur with chronic venous disease but is not seen with venous thrombosis.
Which findings in a client seen at the outpatient clinic support a diagnosis of an arterial ulcer? Select all that apply. One, some, or all responses may be correct. 1 Lack of hair 2 Thickened toenails 3 Copious ulcer drainage 4 Diminished pedal pulse 5 Brown skin discoloration
1 Lack of hair 2 Thickened toenails 4 Diminished pedal pulse Prolonged lack of oxygen to hair follicles results in hair loss. Prolonged lack of oxygen to the toes results in thickened toenails. Inadequate arterial perfusion results in diminished pedal pulse quality. Copious ulcer drainage is associated with venous ulcers, whereas arterial ulcers are dry because of decreased blood flow. Brown skin discoloration is associated with venous disease.
When a client is using a hypothermia blanket to reduce fever, which finding indicates a need for a change in the treatment? 1 Shivering 2 Vomiting 3 Dehydration 4 Hypotension
1 Shivering Shivering should be prevented because peripheral vasoconstriction increases temperature, circulatory rate, and oxygen consumption. Hypothermia therapy does not cause vomiting, and vomiting is not an indication of a need to modify hypothermia. Dehydration is not a response to hypothermia therapy, although fever can cause dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance. Hypotension is not a response to hypothermia therapy, although hypotension can occur with dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance.
When collecting data from a client with varicose veins who is scheduled for sclerotherapy, which symptom will the nurse expect the client to report? 1. Feeling of heaviness in both legs 2. Burning pain in the legs with exercise 3. Calf pain on dorsiflexion of the foot 4. Pallor of the lower extremities
1. Feeling of heaviness in both legs Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when exercising that is relieved by rest (intermittent claudication) is a symptom related to decreased arterial blood flow. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Venous disease typically causes redness of the leg. Pallor is associated with arterial disease and decreased arterial blood flow.
Which findings would the nurse expect when assessing a client with peripheral arterial disease? SATA 1. Pallor of feet 2. Warm extremities 3. Ulcers on the toes 4. Thick, hardened skin 5. Delayed capillary refill
1. Pallor of feet 3. Ulcers on the toes 5. Delayed capillary refill Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit pallor, ulcers on the feet and toes, cool skin, and capillary refill longer than 3 seconds. Warm extremities occur with venous disease. Venous disease leads to thick, hardened skin on the legs.
When a client who is admitted for coronary artery bypass graft (CABG) surgery asks the nurse about the purpose of pacemaker wires inserted during surgery, which explanation will the nurse give? 1 Defibrillation of the heart after surgery 2 Prevention of slow heart rate after surgery 3 Maintenance of rate of at least 100 beats/minute during surgery 4 Inhibition of too-rapid heart rate during the postoperative period
2 Prevention of slow heart rate after surgery Pacing wires are sometimes placed during CABG so that pacing is rapidly available in case of bradycardia during the postoperative period. Pacing wires are not use for defibrillation. The heart is usually placed into cardiac arrest during CABG to facilitate the suturing of grafts into place. Medications to slow heart rate would be used rather than overdrive pacing during the postoperative period after CABG.
When the nurse is administering intravenous potassium to a client with hypokalemia, which finding is most important to communicate to the health care provider? 1 U waves on cardiac monitor 2 QRS duration of 0.28 seconds 3 Decreased bowel sounds 4 Weakened grip strength
2 QRS duration of 0.28 seconds When administering intravenous potassium supplements, it is important to evaluate for clinical manifestations of hyperkalemia. Widening of the Q waves is a potentially fatal manifestation of hyperkalemia (because it may lead to cardiac arrest) and would be communicated rapidly to the health care provider so that the infusion can be stopped and the potassium level can be rechecked. The other findings would be reported to the health care provider but are expected with hypokalemia and are not an indication for a change in treatment. U waves are an expected manifestation of hypokalemia because of changes in ventricular repolarization. Decreased bowel sounds may occur because of decreased peristalsis caused by low potassium levels but should improve with potassium administration. Weakened grips may occur with hypokalemia because normal extracellular potassium levels are needed for skeletal muscle contraction.
Which physiological factors help maintain blood pressure in the client with hypovolemia? Select all that apply. One, some, or all responses may be correct. 1 Arteriolar dilation 2 Release of aldosterone 3 Activation of angiotensin II 4 Sympathetic nervous system activation 5 Stimulation of the vagus nerve
2 Release of aldosterone 3 Activation of angiotensin II 4 Sympathetic nervous system activation In hypovolemia, aldosterone, angiotensin II, and sympathetic nervous system activation all increase blood pressure. Release of aldosterone from the adrenal cortex causes retention of sodium and water, which increases blood volume and blood pressure. Angiotensin II activation causes vasoconstriction, which raises blood pressure. Sympathetic nervous system activation increases heart rate and left ventricular contractility and also causes vasoconstriction. Arteriolar dilation would tend to decrease blood pressure. Vagus nerve stimulation leads to a decrease in heart rate, which tends to decrease blood pressure.
When teaching a client who has a new diagnosis of Raynaud disease, which information will the nurse include? Select all that apply. One, some, or all responses may be correct. 1 Medications will be needed to control the symptoms. 2 Stop cigarette smoking and other tobacco use. 3 Wear gloves when getting food from the freezer. 4 Plan to take a daily low-dose aspirin tablet. 5 Avoid going quickly from a warm to a cold environment
2 Stop cigarette smoking and other tobacco use. 3 Wear gloves when getting food from the freezer. 5 Avoid going quickly from a warm to a cold environment Tobacco use increases the vasospasm that causes Raynaud disease symptoms. Use of gloves when handling cold foods helps prevent triggering of vasospasm in the fingers. Moving quickly from a warm to a cold environment may trigger vasospasm and cause symptoms. Medications such as calcium channel blockers are only used after lifestyle changes are unsuccessful in relieving symptoms. Low-dose aspirin is not used for treatment of Raynaud disease.
When a client who has had a myocardial infarction asks the nurse about why a thallium scan has been prescribed, which answer would the nurse provide? 1 To check heart valve function 2 To establish viability of heart muscle 3 To visualize ventricular systole and diastole 4 To monitor the heart's electrical conductio
2 To establish viability of heart muscle A thallium scan is a radionuclear study that establishes the viability of myocardial tissue; necrotic or scar tissue does not extract the thallium isotope. Heart valve function would be checked with echocardiography or cardiac angiography. Ventricular systole and diastole would also be assessed with an echocardiogram or cardiac catheterization. The cardiac conduction system is monitored with an electrocardiogram.
Which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed? 1 Applying a hot water bottle to the abdomen 2 Using a heating pad to warm the extremities 3 Drinking a warm cup of tea when feeling chilly 4 Turning the room thermostat above 72°F (23.3°C
2 Using a heating pad to warm the extremities The client's extremities are less able to respond to thermal stress because of peripheral vascular problems, and burns may occur with the application of a heating pad to the extremities. Applying heat to the abdomen causes reflex dilation of the arteries in the extremities term-11and increases blood flow without untoward effects. Raising the internal temperature by drinking warm fluid prevents vascular constriction and warms the extremities. Increasing heat of the external environment will safely help prevent arterial constriction and improve client's peripheral circulation.
When discharging a client who has had insertion of a coronary artery stent, the nurse will instruct the client to seek immediate medical attention for which signs and symptoms? SATA 1. Dyspnea with vigorous exertion 2. Unexplainable profuse diaphoresis 3. Indigestion not relieved by antacids 4. Fatigue the day after a rigorous walk 5. Acute chest pain after rigorous exercise 6. Continued chest pain after nitroglycerin use
2. Unexplainable profuse diaphoresis 3. Indigestion not relieved by antacids 5. Acute chest pain after rigorous exercise 6. Continued chest pain after nitroglycerin use These are clinical indicators of inadequate oxygen to the heart. The client should be instructed to seek immediate medical intervention. Dyspnea on vigorous exertion and fatigue the day after a rigorous walk are expected.
Which clinical manifestations would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease? 1. Edema of the feet and ankles 2. Reddened and painful areas on the calves 3. Pain when exercising and thickening of the toenails 4. Ulcers around the ankles and reports of a dull ache in the legs
3. Pain when exercising and thickening of the toenails Inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these adaptations may be associated with decreased cardiac output related to heart failure.
A client who has been admitted with pulmonary edema and received furosemide intravenously needs to void. Which action by the nurse would be best? 1 Place the client on a bedpan. 2 Use adult diapers for the client. 3 Help the client walk to the bathroom. 4 Assist the client to a bedside commode.
4 Assist the client to a bedside commode. Assisting the client to a bedside commode allows the client to keep the head elevated, which is needed in clients with pulmonary edema to improve oxygenation. Placing a bedpan will require that the head of the bed be lowered so that the bedpan can be placed and will increase the client's work of breathing. Using adult diapers on client who is not incontinent is disrespectful and demeaning to the client. Having the client walk to the bathroom will increase cardiac workload, which should be avoided in clients with pulmonary edema.
Which finding by the nurse who is caring for a client who had a left pneumonectomy is most important to communicate to the health care provider? 1 Absent left sided breath sounds 2 Client report of 9 out of 10 incisional pain 3 Blood pressure of 162/90 mm Hg 4 Crackles heard throughout the right lung
4 Crackles heard throughout the right lung Because fluid overload can occur after pneumonectomy because of the loss of a large vascular bed, the crackles need to be reported immediately; the nurse would anticipate actions such as decreasing of intravenous infusion rates and administrating a diuretic. Absent left sided breath sounds are expected after left pneumonectomy. Severe incisional pain indicates a need for administration of prescribed analgesics, but is not life threatening. An elevated blood pressure will be reported to the health care provider, but is not unusual when clients experience pain or stress during the postoperative period.
When a critically ill client has a pulmonary artery catheter inserted, which measurement provides the most useful information about the client's left ventricular pressure? 1 Right atrial pressure 2 Central venous pressure 3 Pulmonary artery diastolic pressure 4 Pulmonary artery wedge pressure
4 Pulmonary artery wedge pressure Pulmonary artery wedge pressure (PAWP) is an indirect measure of left ventricular end-diastolic pressure. Right atrial pressure measures only the function of the right side of the heart, which frequently does not reflect left ventricular function. Central venous pressure (CVP) is the same as right atrial pressure, because the large central veins are contiguous with the right atrium. CVP also reflects right-sided cardiac pressures and is not usually a good indicator of left ventricular function. Pulmonary artery diastolic pressure is frequently a good indicator of left ventricular end-diastolic pressure, but may be inaccurate in clients with chronic obstructive pulmonary disease or pulmonary hypertension.
When the nurse is caring for a diabetic client with a bacterial infection of the foot, which assessment finding indicates a need to activate the rapid response team? 1 Hypertonic bowel sounds in all 4 quadrants 2 Blood glucose level 145 mg/dL (8.1 mmol/L) 3 Client report of level 9 pain of the foot (0 to 10 scale) 4 Systolic blood pressure persistently 85 to 90 mm Hg
4 Systolic blood pressure persistently 85 to 90 mm Hg A systolic blood pressure less than 90 in a client who is at risk for sepsis (such as this client with a bacterial infection and diabetes) indicates possible sepsis and systemic inflammatory response syndrome (SIRS). The nurse would immediately activate the rapid response team and anticipate collaborative actions such as further diagnostic testing, massive fluid infusion, and administration of vasoconstrictive medications. Hypotonic bowel sounds may indicate sepsis or SIRS. Blood glucose levels higher than 140 mg/dL (7.7 mmol/L) might indicate sepsis or SIRS in a nondiabetic client, but would not be unusual in a client with diabetes. Level 9 out of 10 pain would require administration of analgesics, but is not as concerning as hypotension and does not require activation of the rapid response team.